Elsevier

Foot and Ankle Surgery

Volume 25, Issue 2, April 2019, Pages 247-250
Foot and Ankle Surgery

Long-term results after triple arthrodesis: Influence of alignment on ankle osteoarthritis and clinical outcome

https://doi.org/10.1016/j.fas.2017.11.003Get rights and content

Highlights

  • No association was found between alignment and the aggravation of ankle joint osteoarthritis in the long-term in this study.

  • Aggravation of ankle joint osteoarthritis does not relate to patient satisfaction.

  • Clinical outcome 15 year after triple arthrodesis remained stable.

  • Slow radiographic aggravation of osteoarthritis of the ankle joint was seen in 42% of the patients.

Abstract

Background

Pain, deformity and instability are the main reasons for fusion of the tarsal joints, a triple arthrodesis. The short and midterm results show that mobility, function and satisfaction increase postoperatively. However, osteoarthritis (OA) of the adjacent ankle joint is described as a long-term complication. Alignment of the foot could be an influencing factor. The aim of this study was to examine whether malalignment after triple arthrodesis leads to a higher grade of OA at long-term follow-up.

Methods

Between 1991 and 2002, 81 patients underwent a triple arthrodesis. Preoperatively, postoperatively, 3, 7.5 and 15 years after surgery, dorsoplantar (DP) and lateral X-rays were taken and used to evaluate the degree of OA and the geometry of the foot. The degree of OA was estimated using the Kellgren and Lawrence score. The geometry of the foot was assessed using Meary’s angle; a Meary’s angle exceeding 15° in DP and/or greater than −5 to 5° from the lateral view was defined as malalignment. In addition to the radiological evaluation, clinical scores (FFI and AOFAS) were recorded.

Results

Thirty-five patients (40 feet) were available for analysis 15 years after surgery. In 19 cases there was an increase in ankle OA following the operation. Eight feet showed malalignment on the lateral view and 28 on the DP view. There was no difference in both an increase of ankle OA or clinical outcome between correct aligned feet and feet classified as malaligned. Thirty-three patients with 38 treated feet stated that they would decide to undergo the treatment again. Two patients would not want to undergo the same surgery again. The patients were satisfied with the result of surgery, clinical scores improved after surgery and remained stable in the long-term.

Conclusions

Triple arthrodesis is a salvage procedure in patients with a painful and deformed hindfoot and results in a clinically beneficial outcome, even 15 years after surgery. The present study did not show that malalignment after triple arthrodesis results in a higher grade of OA of the ankle joint in the long-term. The cause of the aggravation of OA is still not fully understood and needs further research. Nevertheless, clinical results are satisfying 15 years postoperatively.

Introduction

Medical conditions such as neuromuscular diseases, posttraumatic conditions, rheumatoid arthritis, congenital and flat foot deformities can be the cause of a painful, deformed and/or unstable hindfoot. Due to deformity and pain, disability evolves and consequently the quality of life reduces. Triple arthrodesis, conjoining the talocalcaneal, talonavicular and calcaneocuboid joints, is known as a salvage procedure to restore the form of the hindfoot and reduce pain [1]. Although patient satisfaction is high after a triple arthrodesis, the procedure has a disadvantage, it can lead to degenerative changes of the ankle joint in the long-term [2], [3].

The development of osteoarthritis (OA) of the ankle joint is possibly a result of abnormal stresses placed on the ankle and midfoot joints due to the absence of tarsal movements [3], [4]. After the performance of an arthrodesis, the peak pressure in the ankle joint increases; this might cause an overload of pressure on the joint and consequently results in osteoarthritis [5]. Correct shape and alignment of the foot is pursued to obtain the most natural position of the hindfoot and thus provide optimal pressure distribution in the adjacent joints. However, triple arthrodesis is a technically difficult procedure and correction of the alignment of a sometimes severely deformed foot might not always be as successful as intended. Persistent malalignment after operative correction might cause aggravation of OA in the long-term.

Previously, our group presented the short- and midterm results of patients after triple arthrodesis [6], [7]. It was noted that a certain degree of OA of the ankle joint was already present due to the underlying pathology and/or deformity prior to surgery. Interestingly, it seemed that patients with a valgus position of the ankle more often had aggravation of OA seven years after surgery. Although the results were not statistically significant, it was suggested that aggravation of OA was related to malalignment. Therefore, the aim of the present study was to determine whether the geometry of the foot aggravates OA of the ankle joint 15 years after triple arthrodesis. In addition, the clinical outcome was evaluated and we examined whether this was related to malalignment. We hypothesised that if malalignment persists after operative correction, this will lead to aggravation of OA in the ankle joint in the long-term.

Section snippets

Patients

This study was a follow-up of a previous prospective study investigating the results of triple arthrodesis performed between 1999 and 2002 at the St. Maartenskliniek Nijmegen, The Netherlands [6], [7]. A total of 81 patients who underwent 93 fusions were initially included in the study. In 2003, the short-term results were evaluated in 75 patients, including 87 fusions. Subsequently, in 2008, the midterm results were assessed in 48 patients including 55 feet. Patients who completed the midterm

Results

Thirty-eight of the 48 patients, who completed the midterm follow-up, visited the hospital between November 2015 and June 2016 to participate in the present study. Ten patients were lost-to-follow-up because they passed away (n = 3), withdrew their consent (n = 3), were unattainable (n = 3) or were not able to visit the hospital (n = 1). There were three failures. One patient with rheumatoid arthritis underwent an ankle arthroplasty due to ankle OA grade 4 and progressive pain. The two other patients

Discussion

In the present study good clinical results were found 15 years after surgery in patients who underwent a triple arthrodesis. Patients remain satisfied after the procedure and the pain is significantly reduced. Examining Fig. 3, one might argue that there is a slight tendency towards an increase in disability over time, however this is not significant. This is not surprising as most of the patients included are patients with a progressive neuromuscular disease (CMT). The majority of patients

Conclusion

Malalignment, as defined in the present study, did not result in a significantly higher grade of ankle OA in the long-term. What might cause the increase in ankle OA of the treated patients in the long-term is still unknown. Nevertheless, clinical results are still satisfying 15 years postoperatively. Taking the long-term results into account, triple arthrodesis is a salvage procedure in patients with a painful and deformed hindfoot, resulting in a clinically beneficial outcome even 15 years

Conflict of interest

The authors declare that they have no proprietary, financial, professional, or other personal competing interests of any nature or kind.

Funding

The institution received funding from Anna Fonds to pay for staff and materials. Anna Fonds had no role in the design or conduct of the study, the collection, management, analyses and interpretation of the data, or the preparation and review of the manuscript.

References (16)

There are more references available in the full text version of this article.

Cited by (0)

View full text